Anxiety Disorders

serotonin

feel good neurotransmitter, does not cross the BBB

“head-red-fed”

enterochromaffin cells in GI tract, raphe nuclei in brainstem

90% of serotonin is found where? 10% is found where?

depression, anxiety, memory, impulsivity, sex

“Head” for serotonin?

platelets and bleeding

“Red” for serotonin?

GI motility and nausea

“Fed” for serotonin?

norepinephrine

stimulates sympathetic NV (flight or flight)

excitatory

locus coeruleus

NE is produced where?

concentration, attention, energy

How does NE work on the brain?

tachy, HTN, glucose utilization, decrease GI motility

How does NE work on the body?

excitatory, “on” switch

Is glutamate excitatory or inhibtory?

inhibitory, “off” switch

Is GABA excitatory or inhibitory?

relaxation, euphoria, decrease muscle contraction, slows breathing

What effects does GABA have?

anxiety, seizures

Increased GABA decreases _____ and ______

stimulatory

Histamine is primarily ______ but can have some inhibitory effect

histamine

What neurotransmitter promotes wakefulness?

GABA

Histamine stimulates what?

GABA

All benzos bind to sites that are part of the _____ receptor

frequency, which decreases excitability of nrueons

Benzos increase the ______ of GABA channels opening? which does what?

calming effect on many functions of the brain

Benzos reduce communication b/w neurons and has what effect on the functions of the brain?

liver

Most benzos are metabolized where?

elderly, hepatic dysfunction

When using benzos we will see delayed metabolism in what populations?

lorazepam, midazolam, diazepam

What benzos can be IV/IM?

anxiety, insomnia, agitation, alcohol withdrawal

Indications for benzos?

midazolam

What benzo can be used for sedation/anesthesia?

dizepam, lorazepam, midazolam

What benzos can be used as anticonvulsants?

diazepam

What benzos can be used as muscle relaxants?

physical dependence

All benzos can cause ______ ______

start with lorazepam or clonazepam at a low dose

continue for 2-6 weeks, then in the 6 week period initiate SSRI

How to safely and efficiently adminster benzos?

respiratory depression, esp w/ ETOH/opioids

Benzo overdose?

sedation, impaired concentration

Most common reaction of benzo?

dizziness, ataxia, anterograde amnesia

memory loss, poor attention/concentration, impairment in visuospatial awareness, delirium

dis-inhibition w/ paradoxical agitation and/or aggression

Other S/E of benzo?

increased anxiety/irritability

tremor or shakiness, muscle twitching

sweating

tachycardia, HTN

insomnia

seizures/delirium

Withdrawal sx of benzo?

alprazolam

What benzo has a particularly severe withdrawal?

decrease 255% of dose per week

How to taper benzo dose?

flumazenil

Reversal agents of benzo?

nausea, vomiting, dizzy, agitation and emotionally labile

S/E of flumazenil?

seizures

Flumazenil may precipiate what?

panic disorder, GAD, social phobia

Indications for alprazolam?

euphoria or high reported, which causes abuse potential

less sedating than other benzos

serious problem with withdrawal symptoms

S/E os alprazolam?

anxiety, ETHOH withdrawal, adjunct in acute psychotic agitation

Indications for lorazepam?

lorazepam

What is the benzo of choice if patient has serious or multiple medical conditions because it is not metabolized by P450?

ativan

lorazepam is indicated for patients who are taking ______ TID scheduled dosing

panic disorder, social phobia, GAD

Clonazepam indications?

no

Does clonazepam provide euphoria like xanax?

long acting

Is clonazepam long acting or short acting?

liver disease, because metabolzied by P450

Avoid clonazepam in liver disease why?

anxiety, ETOH withdrawal, adjunctive treatment of muscle spasm, and movement disorders

Indications for diazepam?

long >100 hours

Does diazepam have a long or short half life?

accumulation of active metabolites

The long half life of diazepam leads to what?

long >100 hours

Is the half life of chlordiazepoxide long of short?

anxiety and alcohol withdrawal

Chlordiazepoxide is used for what?

medically incapacitated and can become suddenly obtunded

For chlordiazepoxide what may happen to the elderly because of long half life?

partial serotonin 1A agonist, no involvement with GABA

MOA of buspirone ?

withdrawal/addiction, anti-seizure or muscle relaxant

Buspirone has no risk of ….. and no benefit of…

GAD, depression, OCD

Indications for buspirone?

HA, dizziness, GI upset, fatigue, insomnia

S/E of buspirone?

2-4 weeks

How long does buspirone take to taoe effect?

patients who have taken benzos before

Buspirone has reduecd efficacy in patients who have…

GABA analog calcium-channel modulator antiseizure medication

MOA of gabapentin?

opioid use disorder, potentiate high, street value

Caution of gabapentin?

sedation, dizziness

S/E of gabapentin?

histamine receptor antagonist but also get some anticholinergic effects

MOA of hydroxyzine?

anxiety, insomnia

Hydroxyzine is used to treat?

anticholinergic S/E

hydroxyzine is limited by what S/E?

prolong QTc

Hydroxyzine has what adverse S/E?

increase duration of GABA channels opening

MOA of phenobarbital/pentobarbital?

seizures, anxiety disorders, insomnia

Barbituates are used to treat?

abuse/death

Barbituates are often not used due to risk of what?

women

In anxiety disorders are women or men affected more?

anxity

response to a threat that is unknown, internal, vague

usually insidious

anticipation of future threat

fear

an emotional response to a real or perceived imminent threat

sudden

affect thinking and learning

cause confusion and distortions of perception

decreased ability to relate one item to another

selectivity of attention

In addition to autonomic manifestations, what are other sx of anxiety?

increased NE activity

decreased GABA

serotonin

Neurotransmitter imbalance of anxiety?

extent of distress or impairment

patient preference

CBT alone or in combination with medication

Determining need for anxiety treatment?

four or more

How many sx needed to dx panic attack?

palpitations

abdominal distress

numbness, nausea

intense fear of death

choking, chills, chest pain

sweating, shaking

SOB

PANICSS mnemonic?

recurrent spontaneous, unexpected occurrence of panic attacks

Panic disorder is characterized by what?

attack followed by at least 1 month of worry of repeat panic attack/maladaptive behavior

Time frame of panic disorder?

usually spontaneous, can occur following excitement, physical exertion, sex or moderate emotional trauma

1st attack of panic disorder?

rumination

stammering

impaired memory

Mental status exam of panic disorder may include?

rumination

compulsively focused attention on the sx of one’s distress and on its possible causes and consequences as opposed to its solution

stammering

speaking with many pauses and repetitions

late adolescnece of early adulthood

onset of panic disorder?

increased risk of committing suicide

Panic disorder has increased risk of….

avoid caffeine and nicotine

psychotherapy with or without meds, like SSRI or SNRI

Treatment of panic disorder?

tricyclic/tetracyclic drugs

these are 3rd line for tx of panic disorder, can take 9-12 weeks to achieve clinical response

anticholinergic/toxicity issues

S/E of tricyclic/tetracyclic drugs

mirtazapine

clomipramine

imipramine

Most effective tricyclic/tetrayclic drugs for panic disorder?

benzos, gabapentin

If someone w/ panic disorder is having marked distress what meds can be given?

start w/ clonazepam for 1-2 weeks while initiating SRI, then taper off clonazepam

Best approach if patient having marked distress?

CBT, applied relaxation, in vivo exposure

Therapy for panic disorder?

CBT

instruction about a patient’s false beliefs and information about panic attacks

applied relaxation

training in special breathing and progressive muscle relaxation exercises designed relax voluntarily

agoraphobia

marked or intense fear/anxiety triggered by real or anticipated exposure to a wide range of situations

panic disorder

What can be a comorbidity of agoraphobia?

same as panic disorder

Tx of agoraphobia?

CBT, virtual therapy, family therapy

Therapy for agoraphobia?

phobia

irrational fear that produces a conscious avoidance of the feared subject, activity or situation usually disrupting a person’s ability to function

specific phobia

strong, persisting fear of an object or situation

social phobia

strong, persisting fear of situations in which embarrassment can occur